Client Re-Admission Form

Please take a moment to fill out the form below

To assist in your re-intake process, we require our patients to complete this form. We collect information that provides a deeper insight into your history and helps us tailor the goals of your program for your best possible results. Once you submit this form, we will contact you with information for the next step in treatment.

Client Readmission Form

  • MM slash DD slash YYYY

  • Client (Patient) Information:

  • Funding Guarantor (if different from client)

  • Payment

  • Please describe your current problematic substance use

  • Please note that any nutritional supplement or herbal medicine brought to treatment is subject to confiscation and disposal. Any exceptions must be pre-approved by medical staff.

  • Precipitating Event/Motivation

  • On a scale of 1 to 10 (1 being very low and 10 being very high) rate the extent to which you are currently experiencing the following emotions in anticipation of your return to SCHC

  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • Please enter a number from 0 to 10.
  • This field is for validation purposes and should be left unchanged.
Save and Continue Later